I A F F

International Associationof Fire Fighters®

EMERGENCY MEDICAL SERVICESAdding Value to a Fire-Based EMS System

Monograph 7

i

Emergency Medical ServicesAdding Value to a Fire-Based EMS SystemMonograph 7

Department of Emergency Medical ServicesInternational Association of Fire Fighters, AFL-CIO, CLC

Copyright © 1997 by the International Association of Fire Fighters.® This publication

is protected by copyright. No part of it may be reproduced, stored in a retrieval system,or transmitted in any form or by any means, electronic, mechanical, photocopying,recording, or otherwise without written permission from the International Associationof Fire Fighters, Department of Emergency Medical Services.

International Standard Book Number: 0-942920-28-7

Foreword

Harold A. SchaitbergerGeneral President

Today more than 80 percent of fire departments perform some level of emergencymedical services (EMS), making professional fire fighters the largest group of providersof prehospital emergency care in North America. No other organization – public orprivate – is capable of providing prehospital emergency response as efficiently andeffectively as fire departments. Fire department operations are geared to rapidresponse, whether it is for EMS or fire suppression. Cross-trained/dual-role fire fightersare trained to aggressively attack their work whether it involves a fire, a rescue, or amedical emergency. It is no surprise that study after study has shown that firedepartment-based prehospital emergency medical care systems are superior to otherprovider types.

However, as we look into the future of prehospital emergency medical care, we arecalled upon to evaluate our role and the possible need for change in the context of arapidly evolving medical care system. We must look at what we have learned during thepast century and create a vision for the future of fire-based EMS. This vision mustaddress necessary legislation for the protection of fire-based systems. It must addresspublic education, prevention, and the possible expansion of the scope of practice forparamedics. This vision must consider the effects of managed care organizations onprehospital EMS, as well as revenue recovery for the services fire fighters perform. Itmust also protect fire-based systems from the threat of privatization, as well as protectthe citizens we serve by preserving the nation's universal emergency access number,9-1-1. The information in this series of monographs is designed to guide local firedepartment leaders through the process of developing a vision for the future of a fire-based EMS system.This monograph is the seventh in the series and containsinformation for adding value to a fire department, enhancing the value of the servicestraditionally provided, as well as implementing services beyond those historicallyoffered.

The role of the professional fire fighter is constantly changing. We are called uponto act as multi-faceted first responders answering not only fire calls but rescue,hazardous materials, and emergency medical calls. By answering the challenge ofchange, we can continue to meet the needs of the communities we serve and do whatwe do best –– protect property and save lives.

Acknowledgments

IAFF DEPARTMENT OF EMERGENCY MEDICAL SERVICES

Lori Moore, MPH, EMT-P, Director

The IAFF would like to acknowledge the Department of EmergencyMedical Services staff, specifically Jonathan Moore and Sandy Miller, fortheir work in the development of this guide book.

The IAFF also wishes to recognize the members of the IAFF EMSCommittee for their editorial review and support:

James L. Hill, District 7 Vice President, Co-ChairDominick F. Barbera, District 12 Vice President, Co-ChairRobert B. McCarthy, President, PFF of MassachusettsPatrick Cantelme, President, IAFF Local 493, Phoenix, AZDan Fabrizio, President, IAFF Local 2, Chicago, ILMark A. Lloyd, President, IAFF Local 385, Omaha, NERichard L. Mayberry, President, IAFF Local 522, Sacramento, CAGary Rainey, Secretary, IAFF Local 1403, Metro-Dade Co., FLRonald L. Saathoff, President, IAFF Local 145, San Diego, CA

International Association of Fire Fighters® AFL-CIO, CLC

Department of Emergency Medical Services

1750 New York Avenue, NW

Washington, DC 20006

(202) 737-8484

(202) 737-8418 (FAX)

Adding Value to a Fire-Based EMS SystemTable of Contents

INTRODUCTION ..........................................................................1

I. ADDING VALUE TO A FIRE-BASED EMS SYSTEM ...............2

A. WHAT IS THE AGENDA FOR THE FUTURE OF FIRE-BASEDSYSTEMS? .................................................................................2

Integration of Health Care ..........................................................2EMS Research ..........................................................................3Information Systems ..................................................................6Legislation and Regulation ........................................................7System Finance ........................................................................8Public Education .......................................................................8Prevention .................................................................................9Evaluation .................................................................................9

B. ONGOING QUALITY IMPROVEMENT...................................10Types of QA/QI and Timing Considerations .............................10QA/QI Content Considerations ................................................12QA/QI Process Considerations ................................................12

II. FIRE-BASED EMS "VALUE ADDED SERVICES"................14

A. CHANGING NEEDS IN THE COMMUNITY ...........................14

B. DESCRIPTIONS OF VALUE ADDED SERVICES ...............15Injury Prevention & Public Education ........................................15Elder Patient Follow-Up ...........................................................17Inter-Facility Transport .............................................................18CPR Classes ..........................................................................19Automated External Defibrillation .............................................19Community Outreach ...............................................................19Primary Care/Expanded Scope of Fire-Based EMS Provider Practice .................................................................................20

CONCLUSION ...........................................................................22

Appendix 1. EMS Database Elements

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1

INTRODUCTION

The fire service is a multi-faceted, multi-disciplined organization. By nature,

fire fighters are America’s first responders regardless of the type of emergency.

Cross-trained/dual-role fire fighters are trained to handle the most time-critical

events on a scene, whether fire suppression, rescue, or EMS. Emergency

medical services include medical first response, rescue and extrication,

basic life support (BLS), advanced life support (ALS), transport services, and

disaster coordination. This ability to continually handle such a wide range of

emergencies comes from the fire service’s ability to monitor the needs of the

community and adapt to meet those needs.

Community needs will continue to change because of social and economic

pressures as well as sweeping health care reform. Fire department leaders

must assess the strengths and weaknesses of their EMS systems and

determine if extending or improving the services already offered or implementing

new services would add value to their departments in the future. Efforts to

extend or improve core emergency response and transport services can be

addressed by implementing quality assurance or quality improvement

programs. Other enhancements include EMS research activities, passing

legislation or regulatory statutes to maintain the integrity of fire-based EMS

systems, or seeking capitated managed care agreements to provide revenue

for existing services.

Additional services should be considered for fire departments that consistently

meet the community’s needs in the delivery of core emergency components.

Value added services can include injury prevention programs, elderly patient

follow-up, inter-facility transport, teaching CPR classes, and perhaps primary

health care.

This monograph discusses enhancements to existing services that add value

to the department, as well as additional services that are considered “value

added services.”

2

WHAT ISHAT IS

whatWHAT

I. ADDING VALUE TO A FIRE-BASED EMS SYSTEM

A. WHAT IS THE AGENDA FOR THE FUTURE

OF FIRE-BASED SYSTEMS?

In 1996, the 30th anniversary of the emergency medical service industry,

the National Highway Traffic Safety Administration (NHTSA) looked at the

status of EMS nationwide, developed a vision for the future of EMS, and

published findings in “EMS Agenda for the Future” (available through the

U.S. Government Printing Office). NHTSA predicts that EMS systems of

the future will be community-based health management systems that are

fully integrated with the overall health care system. NHTSA also states that

the future EMS systems will have the capability to identify and reduce

illness and injury risks through prevention, provide acute illness and injury

care and follow-up, assist in the treatment of chronic conditions outside

hospitals, and provide community health monitoring. It is projected that

EMS will be further integrated with other health care providers, as well as

public health and public safety agencies. EMS providers will improve

community health and bring about more appropriate use of acute health

care resources like the hospital emergency departments. Yet, even in light

of predicted changes, NHTSA’s “EMS Agenda” recognizes that EMS

providers will remain the public’s emergency medical safety net.1

In an effort to realize this vision, NHTSA’s “EMS Agenda” proposes the

continued development of fourteen components of EMS services.

• Integration of Health Services

• EMS Research

• Legislation and Regulation

• System Finance

• Human Resources

3

• Medical Direction

• Education Systems

• Public Education

• Prevention

• Public Access

• Communication Systems

• Clinical Care

• Information Systems

• Evaluation

Many of these components represent well established elements of fire-

based EMS systems. Others, however, should be considered as potential

service enhancements for fire departments. Looking toward the future,

these components are discussed below.

Fire-based EMS systems were created to meet the immediate needs of

the acutely ill and injured for stabilization and transportation. Current fire-

based EMS providers regularly meet these objectives in a rapid, effective

manner. Most fire-based EMS systems, however, are not designed to

provide additional health care services. Adjustments, however, can be

made to integrate other health services.

Patient care follow-up and patient advocates are services which fire-

based systems can integrate with existing duties. For example, the

Metro-Dade County Fire Department provides a program called Elder-

Link. This program allows fire department emergency responders to

enter elders, with non-emergency needs, into the social services network.

EMS providers are in a unique position to determine when the needs of

their patients are likely to extend beyond immediate care and transport.

Without this follow-up, vulnerable elderly could fall between the cracks of

the local health care system.

Another example of an EMS/health service integration is the joint effort

INTEGRATION OF

HEALTH CARE

4

between the Lee County, Florida public health department staff and fire-

based EMS personnel. EMS personnel in Lee County assist in providing

widely needed pediatric immunizations or tuberculosis testing. In this cost

effective approach to preventing communicable diseases, everyone

benefits.

Research involves the search for answers. Research in the field of EMS,

typically is conducted to improve the effectiveness and efficiency of

emergency medical care. Ultimately, EMS research is an effort to

improve care and resource allocation.2

Research can be highly useful in efforts to preserve or improve fire-based

EMS systems for the future. Answers to questions about the impact of

EMS services on the public’s health are particularly crucial. For example,

how do EMS systems impact morbidity, mortality, and costs of traumatic

injuries and emergency illness? Additionally, as an integral part of the

nation’s health care system, EMS is being subjected to critical review, not

only with regard to how well EMS systems perform but also, whether that

performance is worth the cost.

• EMS System Data Collection

Fire-based EMS systems should implement a data collection system.

EMS data collection enables EMS researchers, including system

medical directors, to evaluate and improve access to emergency

medical care for individuals with severe injuries or illnesses. The

overall goal of EMS is to reduce morbidity, mortality, and the impact on

the financial and social impact of illnesses and injuries on our society.

Data collection is crucial in determining whether EMS systems meet

that goal. Following outlines the steps to begin.

First, determine the existing resources within the system. (i.e. engines,

ambulances, paramedics, etc.) in addition to emergency apparatus

EMS RESEARCH

5

and staffing, assessments must include answers to the following

questions.

- How many hospitals are within the jurisdiction?

- What is the level of training of prehospital personnel?

- What equipment is carried by responders?

- What additional training is needed?

- What funding resources are available?

Second, determine the pattern of use of the system.

- Who uses the system?

- How many children?

- How many elderly?

- How many cardiac emergencies?

- What geographic location is the busiest?

Third, determine what the system does.

- What procedures are provided in the prehospital arena?

- Are the procedures provided correctly?

- Does the system have appropriate medical direction?

Fourth, determine if the system is time efficient.

- How long does call intake and dispatch take?

- What are average and fractile response time intervals?

- What are average on scene times, grouped by incident type?

Fifth, determine if the system is effective.

- What have been the trends in overall population mortality,

particularly mortality from injuries?

- Do cardiac arrest patients resuscitated in the field survive

to discharge? One year post discharge?

- Does early ALS affect return of spontaneous circulation in

the field?

- How satisfied are patients with the EMS system?

6

Additional observational research objectives include:

- What happens to the pattern of EMS use following public

education efforts?

- Are the efforts of preventative efforts measurable by lowered

incidence of specific injuries (for example, fewer children

with head injuries after education on bike helmet use)?

• Uniform Data Collection

There are likely to be several obstacles to uniform EMS data collection,

including the following.

- Data exist in several different locations, such as prehospital

records, emergency department records, and vital statistics

records.

- There is no defined, uniform set of data elements to be collected.

The second obstacle, at least, may be overcome by using Uniform

Prehospital Emergency Medical Services data element definitions. The

list of data elements and definitions that should be included in a fire-based

EMS data set can be found in Appendix 1 of this monograph. Fire service

leaders must recognize that data is power. Objective data regarding local

EMS systems can serve to justify, protect, or enhance the systems in the

future.

The ability of research to provide conclusions supporting the fire-based

system depends partly on valid information. Information collection systems

record and arrange data for future use. With available technology, data

can be easily collected, stored, and retrieved. Once collected, the

information can be used for multiple purposes including system

effectiveness research and evaluation of pilot projects. The most efficient

information system allows providers to enter data according to specified

INFORMATION SYSTEMS

7

uniform definitions, with that data being available for retrieval for billing

purposes and multijurisdictional research.

An example of a data collection system is the National Fire Incident

Reporting System (NFIRS). Researchers can access this database to

perform statistical analysis and formulate conclusions. Insurance

companies can receive claim information, and fire departments can

maintain accurate records of activities. Many state EMS systems have

designed Patient Care Records (PCRs) using one standardized form

statewide. Copy of call records are then made available for use in the

statewide EMS database. Similar standardized reporting systems exist

for cardiac arrest (Utstein Template) and trauma events (Triss Method).

Regardless of the method of data collection, fire-based EMS systems

must begin the process of information gathering to facilitate effective

research of fire-based EMS system design.

Within the United States and Canada, each state or province has legislation

providing statutory basis for EMS activities and programs.

State governments have found that it is in the public’s interest to assure

that EMS is available, coordinated, and of acceptable quality and generally

provide some funding.3 Provincial governments, however, are planning

to stop central government EMS funding; provision of EMS will become

the responsibility of local communities.

EMS laws vary from state to state and from province to province, particularly

in requirements for EMS system components. Regulatory agency

flexibility under these laws varies as well. EMS legislation leads to EMS

rules and regulations that affect the design and operation of all EMS

systems. It is vital for fire service leaders to monitor and amend pending

LEGISLATION AND

REGULATION

8

legislation to protect or implement fire-based EMS systems. (See also

IAFF Emergency Medical Services, Monograph 2, “EMS Legislation” for

more information about how to become involved in the legislative process.)

Personnel, equipment, training, supplies, medical direction, and

operational expenditures are required to provide prehospital care.

Taxpayer subsidy is in place to provide for fire department operations in

general, and perhaps fire prevention as well. But the added cost of

exclusively EMS items may challenge departmental financial viability.

Fire-based EMS system survival may depend on tight budgetary controls

and development of supplemental income sources.

EMS revenue may be generated by “fee-for-service” systems, capitated

agreements with health insurers, or subscription programs. Fee-for-

service programs charge individual patients for care provided based on

the services rendered. Capitated agreements may pay providers a

negotiated rate per health organization member transported per month

(both emergency and inter-facility). Some of these agreements may also

allow payment for providing follow-up, patient education, or prevention

services. Finally, subscription programs allow the public to prepurchase

EMS services and avoid being charged additional fees when the service

is used. (See also IAFF Emergency Medical Services, Monograph 4,

“Revenue Recovery, for more details on how fire-based EMS systems can

generate revenue.)

Public education may include prevention efforts, as well as public relations.

While fire and injury prevention efforts assist the citizens by reducing the

likelihood they will require EMS assistance, public relations programs

should introduce them to the system that is in place to respond when

assistance is required.

Emergency response providers are constantly in the public eye. This high

visibility can provide opportunities for public relations and “marketing”

efforts. Citizens decide how fire-based systems will evolve in the face of

SYSTEM FINANCE

PUBLIC EDUCATION

9

economic restraint. By educating them on the value and necessity of fire-

based EMS services, we may preserve the effective and efficient fire-

based systems already in place. Examples of public education topics

other than prevention might be “What happens when I dial 9-1-1?”, “What

does a fire fighter/paramedic do?”, or “What are the services available

from this EMS system?”

Public education sessions should be tailored to the individual needs of

audience. Audiences may include: community members, health care

professionals, policy makers, law makers, and insurance providers. All

public education and public relations efforts should be evaluated.

Evaluation helps ensure that the intended message is received by the

audience and provides guidance for program modifications. Fire-based

EMS public relations materials are available from the IAFF.

Injury prevention is increasingly important for both improving the nation’s

health and truly controlling health care costs.4 Injury is the third leading

cause of death and disability in all age groups, and accounts for more

years of potential life lost than any other health problem.5 In response,

EMS systems are emphasizing wellness and prevention in community

outreach efforts to keep illnesses and injuries from ever occurring. These

primary injury prevention programs present an opportunity to enhance the

health of the community, as well as the relationship between the fire-

based EMS system and the taxpayers.

To provide the best care, EMS system must be evaluated and modified

to meet the changing needs of the community served. Evaluation is the

essential process of assessing the quality and effects of EMS so that

strategies for continuous improvement can be designed and

implemented.6 There are several approaches to this evaluation

component, all of them having “quality” as the focus; quality assurance

(QA), quality control (QC), quality improvement (QI), continuous quality

improvement (CQI), and total quality management (TQM). Key areas to

PREVENTION

EVALUATION

10

be evaluated include the following.

• Response Times

• Level of Training

• Resource Utilization

• Skill Retention

• Communication System

• Patient Outcome Studies (Cardiac, Trauma, Pediatric)

• Paramedic Performance

B. ONGOING QUALITY IMPROVEMENT

To justify what fire departments do currently, or to enhance effectiveness,

many departments are utilizing various versions of “Quality Assurance”

(QA), “Quality Improvement” (QI), “Continuous Quality Improvement”

(CQI) or “Total Quality Management” (TQM). Regardless of name given

to efforts to ensure high quality services and products, the common

element is meeting the needs of those who pay for and use the services

and products provided by an organization.7

Quality Assurance is the sum of all activities undertaken to provide

confidence that the products or services available maintain standards of

excellence established for those products or services. Quality assurance

asks whether system components are being used properly, comparing

their use with some predetermined standard. 8

Quality Improvement is the sum of all activities undertaken to

continuously examine and improve the products and services. Quality

improvement activities are described as being prospective, concurrent,

or retrospective depending on when they are conducted in relation to an

event (for example, relative to a call for prehospital medical care).

• Prospective QA/QI activities are useful in preventing problems.

While prospective QA/QI is essential, their expense and the time that

must be devoted may be seen as disadvantages. EMS personnel

TYPES OF QA/QI AND

TIMING CONSIDERATIONS

11

education and periodic skills evaluation are examples of prospective

QA/QI activities.

• Concurrent activities occur as an event takes place. For example,

concurrent QA/QI activities may include direct observation of a

paramedic’s performance in the field by supervisors. Additionally,

indirect observation may take place by the on-line medical director

during radio or telephone communication. Concurrent QA/QI activities

are highly relevant and are more meaningful if improvements are

made in a timely manner. Using evaluation models for employee

discipline, however, defeats the purpose and reduces the effectiveness.

Concurrent QA/QI efforts can be expensive, if done randomly, and

may cause inconsistencies in retraining or continuing education

efforts. Direct observation may also affect EMT and paramedic

overall performance, because people tend to act differently when they

know they are being watched (the “Hawthorne effect”).

• Retrospective review is a type of systems evaluation and can be

divided into four areas:

Debriefing — discussion of events with the receiving physician

or designee

Critique sessions — recreation of events at a later time with all

parties involved sharing the key points from the event (also

known as morbidity/mortality conferences)

Chart review — checking the EMS chart for completeness,

accuracy, logic, and correlation with attending physician’s

emergency department record

Chart audit — comparing charting with established policies

and procedures to determine personnel compliance levels

12

While these activities do not necessarily help the individual patient who

has received care, they increase overall system value by improving future

service. Retrospective QA/QI approaches are inexpensive and can focus

on target areas, for example, evaluating the appropriate use of oxygen in

the patient with chest pain.

Regardless of design, quality assurance programs must contain

mechanisms that evaluate the following standards.

System Structure Standards — These standards address compliance

with government mandates for resources, such as response vehicles and

trained responders, within the EMS system. Structure studies ensure that

the mandated resources are available, but do not evaluate the impact

those resources have on patient care.

System Process Standards — The use of EMS System resources and

the appropriateness of such utilization. Process evaluation can answer

questions like “What parts of the system work?” or “What component does

not work and requires modification?”

System Outcome Standards — The results of the care given the patient.

Outcome evaluation is a necessity in measuring the overall effectiveness

of an EMS system. When the QI process recommends a change in the

system that may affect patient care, the effectiveness of that change

should be assessed.

The process of QA/QI is best defined as a continuous loop. Regardless

of the timing or the focus of review, any findings must be considered part

of a dynamic cycle of change. Each new finding may lead to a system

modification, which would then require further evaluation of its predicted

effectiveness. This may also be called a system safeguard cycle (Figure

1).

QA/QICONTENT

CONSIDERATIONS

QA/QI PROCESS

CONSIDERATIONS

13

A continuous quality improvement (CQI) program, like other value added

services, can assist fire department leaders at the local level in identifying

the parts of their systems that must be adjusted to meet the changing

needs of their communities. As suggested changes are made, they must

be evaluated for their effectiveness. Having a continuous evaluation tool

in place adds credibility and value to a fire-based EMS system.

Figure 1.

CQI Cycle

14

II. FIRE-BASED EMS “VALUE ADDED SERVICES”

In addition to the fundamental services described in the “Agenda for the

Future” above, fire departments should consider expanding services in

the following areas when planning for their future role in their communities.

• Injury Prevention and Public Education

• Elderly Patient Follow-up

• Inter-Facility Transport

• CPR Classes

• Automated External Defibrillation

• Community Outreach

• Primary Care/Expanded Scope of Fire-Based EMS

Services

A. CHANGING NEEDS IN THE COMMUNITY

The following is a list of changing community needs that may require

additional services within fire departments providing prehospital EMS.

• Fire prevention activities have decreased the number of fires and fire

related injuries.

• Managed Care Organization (MCO) pre-authorization systems triage

calls away from 9-1-1 emergency services.

• Third party payers of health care services want patients transported to

the most appropriate “in-plan” facility. This facility may not be the

hospital emergency department. Or, payers may not want patients

transported at all, leading to home care or treat and release programs.

15

• Communities want to be prepared and educated to handle

emergencies and major disasters situations.

• Public health agencies plan to make a special effort to ensure that

all children are immunized.

• Citizens, recognizing American Heart Association

recommendations, want all EMS first responders to carry

defibrillators.

• Satellite hospitals and nursing homes want reliable inter-facility

transport providers.

• Social service professionals need EMS personnel to follow-up

patients sent home with chronic illnesses.

B. DESCRIPTIONS OF “VALUE ADDED SERVICES”

Fire department personnel already have experience in public fire

safety education, distributing smoke alarms, and teaching children

appropriate behavior in case of fire. The advantages of injury prevention

over injury care are not difficult to understand whether the injuries are

related to fire or other trauma. Fire departments can build on their

community education efforts to include other causes of injuries in their

jurisdictions. Programs can be developed to teach vehicle air bag

safety, seat belt and bicycle helmet use. Efforts can also include health

promotion, such as immunization promotion.

It is widely recognized that injury prevention is more cost-effective than

injury treatment. Nevertheless, it is useful to collect data to show the

value of specific injury prevention efforts. For example, at least one

study found safety belt use reduced hospital admissions from crashes

INJURY PREVENTION AND

PUBLIC EDUCATION

16

by 65% and hospital charges by 67%.9

The Tucson, Arizona Fire Department conducted a highly successful

injury prevention program. As a result of preventive efforts and public

education initiatives, child drowning-related deaths in Tucson have

decreased by more than 50%.10

Injury Prevention Opportunities:

• In 1992, the American Academy of Pediatrics established October

as “Child Health Month.” The first Monday in October was chosen

as “Child Health Day” to create public awareness of the value of

preventive health care for children. During this time period, fire

departments can distribute educational materials or host special

child safety classes. Injury and disease prevention is the cornerstone

of pediatric health care. Promotional materials can be obtained free

of charge from the American Academy of Pediatrics at (800) 433-

9016.

• Similarly, a week in February has been chosen as “National Child

Passenger Safety Awareness Week.” This is an opportunity to

remind the community that taking time to protect children in cars

takes only a few moments. Fire departments can conduct child safety

seat clinics at fire stations. Fire Fighters can provide free inspection

and installation of child safety seats. Brochures are available from

the National Highway Traffic and Safety Administration at (202) 366-

5440.

• The National Highway Traffic Safety Administration has also released

“Safety Advice From EMS (SAFE): A Guide to Injury Prevention.”

The SAFE manual was created using relevant traffic safety information

and injury data. This information was then enhanced with EMS-

specific references by a panel of safety and EMS professionals. The

manual is designed for use by prehospital EMS providers. It can be

used in presentations for various age groups in different settings.

Eleven lesson plans include: Child Safety Seats, Occupant Protection

17

for Adults, Pedestrian Safety for Elders, Teens Driving Under the

Influence, and Yielding to Emergency Vehicles. Along with the detailed

lesson plans are safety and EMS resource lists, as well as a 38 minute

video to enhance the presentation. The SAFE Kit can be obtained

free of charge from the National Highway Traffic and Safety

Administration at (202) 366-5440.

• Using materials generated by the National Safety Council “Air Bag

Safety Campaign,” departments can educate their community on the

benefits and safety concerns related to vehicle air bags. The “ABC’s”

program also targets injuries to children, “Air Bag Safety: Buckle

everyone! Children in back!” For more information contact the Air Bag

Safety Campaign at (202) 625-2570. This proactive approach could

reduce the number and cost of vehicle air bag injuries to children and

adults who do not use seat belts.

Fire department programs targeting injury prevention and safety increase

a department’s visibility and value leading to greater community and

political support.

Metro-Dade Fire Rescue in Florida participates in “Elder-Links,” an

innovative program to improve the health of the community’s elderly. After

an elder calls 9-1-1 for assistance, responding fire EMS personnel

conduct an initial evaluation. If personnel determine that the elder has non-

medical needs, the client is referred to the Elder-Links Project. The

project assesses the elder’s need for preventive community-based

services. This program, thus, serves as a safety net for elderly persons

who are vulnerable to abuse, neglect, or exploitation which may be

indicated by repeated “non-medically oriented” emergency calls. This is

an extended service of Metro-Dade Fire Rescue. More information about

this extended service can be obtained by contacting the Elder-Links

Project at (305) 670-5556.

ELDERLY PATIENT

FOLLOW-UP

18

Fire departments should consider instituting inter-facility transport services

to augment their ability to care for more critically ill or injured patients. Fire-

based EMS systems can increase the number of revenue generating

transports by establishing inter-facility transport contracts with area

hospitals, nursing facilities, and health insurers. These contracts are

secondary to the provision of emergency response and must not

compromise the integrity of the emergency system. Following are models

that may be used in beginning an inter-facility transport service.

• A fire department provides ALS first responder and transport

services — To implement inter-facility transport, additional transport

vehicles could be added to the fleet (number and operating time based

on need, for example, 10 a.m. - 5 p.m., Monday through Friday) and

staffed by fire fighter EMTs and paramedics called in for overtime.

• A fire department provides BLS first response with defibrillator

and ALS/BLS transport — To implement inter-facility transport, the

department could deploy additional transport capable vehicles on a

full 24 hour, 7 day basis staffed with full-time paid cross trained

personnel. This model would provide the opportunity for field personnel

to be rotated between various duties within the department not having

personnel solely dedicated to transport duty.

Both models above offer opportunities for fire departments to contract

with nursing home facilities, hospitals with satellite facilities, urgent care

centers, and managed care organizations. The revenue generated from

providing these additional services should more than offset the cost of the

implementation. Cost analysis and planning assistance may be requested

from the IAFF on these and other models.

INTER-FACILITY

TRANSPORT

19

The American Heart Association defines four components in the “chain of

survival.” These are: early access, CPR, defibrillation, and advanced

cardiac life support (ACLS). In a study published in 1993, “Predicting

Survival From Out-of-Hospital Cardiac Arrest: A Graphic Model”

researchers found significant relationships between each of these ‘“links”

and survival from out-of-hospital cardiac arrest. The predictive model

shows that, as the time from collapse to bystander CPR lengthens, the

likelihood of patient survival decreases.11 Fire departments can increase

patient survival by ensuring that the system includes all four links in the

chain of survival. Access to 9-1-1 and rapid response times are crucial;

however, the fire department can strengthen the CPR link by teaching a

portion of the community to provide CPR. This training increases the

availability of bystander CPR, enhancing the overall effectiveness of the

fire-based EMS system, positively affecting cardiac arrest outcomes,

and adding value to the fire department.

The third link of the chain of survival is defibrillation. The American Heart

Association, National Institutes of Health, and other national EMS

organizations have called for automated external defibrillators to be

placed on every first response vehicle.12 Research has documented the

high value of fire fighter defibrillation in both the United States and

Canada.13 Rapid defibrillation with automated external defibrillators

improves cardiac arrest outcomes, increasing the fire department’s value

to the community. Ideally, defibrillation is followed by ACLS services, also

provided by the fire department.14

In October 1993, the Texas Department of Health sponsored the first

workshop in the nation to teach paramedics to administer vaccines.

Since then, paramedics throughout Texas have immunized thousands of

children as part of the state health department’s “Shots Across Texas

program.

CPR CLASSES

AUTOMATED EXTERNAL

DEFIBRILLATION

COMMUNITY OUTREACH

20

In April 1994, Lee County, Florida public health unit nurses trained three

Lee County EMS paramedics and two paramedics from a local fire

department to perform and interpret TB tests. In May, those paramedics

screened nearly 100 students in an elementary school where several

cases of TB had been reported. In July, those paramedics also began

monitoring TB patients to ensure that patients regularly take their

medications.

Using the Texas Health Department’s “Shots Across Texas” and Lee

County’s TB testing programs as models, fire department paramedics

could conduct immunizations and TB testing in the community. Additionally,

the Health Care Finance Administration states that the Medicare program

will pay for influenza vaccine and its administration.15 These important

disease prevention programs can thus benefit fire departments (as a

source of revenue) as well as citizens.

Immunization and disease screening projects are also excellent for

increasing community outreach and building public relations. The technical

skills and knowledge build on paramedic training. However, the skills

required to conduct these programs may be limited to certain occupations

(for example, registered nurses and physicians). Check with state EMS

officials before proceeding with any outreach programs that involve

administering any vaccines or medicines.

The scope of practice refers to the legal boundaries of medical care

provider actions as defined by individual states. A clear scope of practice

precisely defines what actions can be taken by each category of medical

professional. Other than the paramedic’s “role” statement found in the

Paramedic National Standard Curriculum, the scope of practice for

paramedics has not yet been standardized.

In addition to programs such as the immunization projects described

PRIMARY CARE/EXPANDED SCOPE OF

FIRE-BASED EMSSERVICES

21

above, paramedics have undertaken pilot programs to provide primary

care, including blood pressure monitoring and workplace medical

surveillance screening. There are both advantages and disadvantages

to expanding the scope of practice of the paramedic to include primary

patient care or illness prevention. Regardless of their expanded

responsibilities, however, EMS personnel must make the integrity of the

9-1-1 emergency response system their first priority. It is crucial that this

essential public service be accessible to all citizens in the community.

(See also IAFF Emergency Medical Services Monograph 6, “Paramedic

Expanded Scope.”)

22

CONCLUSION

As the needs of communities change, fire service leaders may explore

options for adding value to their departments. To ensure success, efforts

must meet needs documented by research. Research must also be used

to assess the value of additional services and ensure the highest quality

possible.

Moreover, fire-based EMS leaders must remain committed to ensuring

that the integrity of the primary mission — providing rapid, effective on-

scene emergency care — is maintained.

23

ENDNOTES 1 NHTSA, “EMS AGENDA FOR THE FUTURE,” AUGUST 1996, P. V.2 NHTSA, “EMS AGENDA FOR THE FUTURE, “ AUGUST 1996, P. 13.3 NHTSA, “EMS AGENDA FOR THE FUTURE,” AUGUST 1996, P.17.4 MARTINEZ, R., “INJURY PREVENTION: A NEW PERSPECTIVE,” JAMA1994;19:1541-1542.5 BAKER S.P., O’NEILL B., ET AL., THE INJURY FACT BOOK, 2ND ED, NEW YORK:OXFORD UNIVERSITY PRESS, 1992.6 NHTSA, “EMS AGENDA FOR THE FUTURE,” AUGUST 1996, P.57.7 NHTSA, “A MODEL QUALITY IMPROVEMENT PROGRAM FOR STATEWIDE EMSMONITORING AND EVALUATION,” 1996 DRAFT, P. 3.8 U.S. DEPT. OF HEALTH, EDUCATION & WELFARE “EMERGENCY MEDICAL SERVICES

AT MIDPASSAGE,” NATIONAL ACADEMY OF SCIENCES PRESS, 1978.9 MUELLER, ORSAY E., ET AL., “EFFICACY OF MANDATORY SEAT BELT USE

LEGISLATION”, JAMA, 1988, 260:3593-7.10 KRAKEEL, J., “FOLLOWING THE AGENDA,” FIRE CHIEF, JANUARY 1997, P.33.11 LARSEN, M. ET AL., “PREDICTING SURVIVAL FROM OUT-OF-HOSPITAL CARDIAC

ARREST: A GRAPHIC MODEL,” ANNALS OF EMERGENCY MEDICINE, NOVEMBER 1993,22:11, P.14.12 “CURRENTS IN EMERGENCY CARDIAC CARE,” AMERICAN HEART ASSOCIATION, 7:1,SPRING 1996.13 SHUSTER, MICHAEL MD., “EFFECT OF FIRE DEPARTMENT FIRST-RESPONDER

AUTOMATED DEFIBRILLATION”, ANNALS OF EMERGENCY MEDICINE, 22:4, APRIL 1993,P. 725.14 LARSEN, M., ET AL., “PREDICTING SURVIVAL FROM OUT-OF-HOSPITAL CARDIAC

ARREST: A GRAPHIC MODEL,” ANNALS OF EMERGENCY MEDICINE, NOVEMBER 1993,22:11, P.14.15 “HCFA TO PAY FOR EMS-ADMINISTERED FLU SHOTS,” EMS INSIDER, 23:9,SEPTEMBER 1996, P. 1.

24

GLOSSARY

Capitation: A method of payment for services in which, based on a pre

negotiated contract, a health care provider is paid a fixed amount per

person per month, regardless of whether the individual actually uses the

health care system. This system transfers the risk from the insurance

payer to the health care provider.

Cardiac Arrest – A condition in which the hearts electrical impulses

suddenly become chaotic.

Cardiac Defibrillation – The procedure of delivering electrical shocks to

a victim in ventricular fibrillation (a rapid, non-functional pulsation of the

heart) as a means of trying to restore functional rhythm and pulse.

CPR (cardiopulmonary resuscitation) – The combination of artificial

respiration and manual artificial circulation that is recommended for use

in cases of cardiac arrest.

Cross-Trained/Dual-Role (CT/DR) – An emergency service that allows

personnel trained in emergency situations to perform to the full extent of

their training, whether the situation should call for firefighting or medical

intervention for a victim. This system type offers a greater level of

efficiency than its single-role counterparts.

Defibrillation – The delivery of a very large electrical shock to a part of the

chest/heart. Stops the abnormal activity and allows the heart to restart

normally on its own. Defibrillation is required to reverse cardiac arrest and

restore functional cardiac activity. It can be effective when applied soon

after the onset of cardiac arrest.

25

EMS System – A comprehensive, coordinated arrangement of resources

and functions which are organized to respond in a timely, staged manner

to targeted medical emergencies, regardless of their cause and the

patient’s ability to pay, and to minimize their physical and emotional

impact.

Fee-for-service: A system in which a health care provider charges a fee

for each service performed.

Discounted fee-for-service: A system in which a health care provider

is paid on a fee-for-service basis, but agrees to a discount of the usual

charges.

Health Maintenance Organization (HMO): An organized system of

health care that provides directly or arranges for a comprehensive range

of basic and supplemental health care services to a voluntarily enrolled

group of persons under a prepayment plan (per person per month).

Public Education – Public education imparts knowledge or training in

specific skills. For example, teaching CPR, how to call for help properly,

bicycle safety or briefing public officials about the importance of your

service to your community are all public education activities.

Public Information – Public information is “news.” For example, the

facts about an issue of public concern or a major incident in your

community, or routine communications such as announcing upcoming

events, or a presentation on your annual budget and projected needs

would all be considered pubic information.

Public Relations – Public relations is the process of shaping public

opinion. Public relations is part of every aspect of your service, including

public information and public education activities.

- 1 -

APPENDIX 1. EMS Database Elements1

NAME DEFINITION Age Patient's age or best approximation Agency/Unit Number Number that identifies the agency and unit responding to an accident Cause of Injury External cause of injury Chief Complaint Statement of problem by patient or other City of Residence City or township of patient's residence Crew Member One Number Personnel certification/license number for first crew member Crew Member One Type Personnel certification/license level of first crew member Crew Member Two Number Personnel certification/license number for second crew member Crew Member Two Type Personnel certification/license level of crew member Crew Member Three Number Personnel certification/license number for third crew member Crew Member Three Type Personnel certification/license level of third crew member Date of Birth Patient's date of birth Date Incident Reported Date the call is first received by PSAP or other designated entity Date Unit Notified Date response unit is notified by EMS dispatch Destination/Transferred to Health care facility or prehospital unit/home that received patient from EMS responder providing this record Destination Determination Reason a transport destination was selected Diastolic Pressure Patient's diastolic blood pressure Factors Affecting EMS Delivery Special circumstances affecting the EMS response or delivery of care Gender Sex of patient/victim Glasgow Coma Score (Total) Patient's total Glascow coma scale score Glasgow Eye Opening Component Patient's eye opening of the Glasgow coma scale Glasgow Motor Component Patient's motor component of the Glascow coma scale

1Uniform Prehospital EMS Data Consensus Development Conference.

- 2 -

NAME DEFINITION Glasgow Verbal Component Patient's verbal component of the Glascow coma scale Incident Address Address where patient was found, or address to which unit responded Incident City City or township where patient was found Incident County County or parish where patient was found Incident Number Unique number for each incident reported to dispatch Incident/Patient Dis position End result of EMS response Incident State State, territory, province or district where patient found Initial Cardiac Rhythm Initial monitored cardiac rhythm as interpreted by EMS personnel Injury Description Clinical description of injury type and body Injury Intent Intent of individual inflicting injury Lights and Sirens to Scene The use of lights and sirens to scene Lights and/or Sirens From Scene Use of lights and/or sirens from the scene Location Type Type of location of incident/rural, inner city, etc. Medication Name Medication name Onset Date Date of onset of symptoms or injury date Onset Time Time of onset of symptoms or injury time Patient Care Record Number Unique number for each patient care record (PCR) Patient Street Address Patient's street address Pre-existing Condition Pre-existing medical conditions known to the provider Procedure Attempts Total number of attempts for each procedure attempted, regardless of success Procedure or Treatment Name Identification of procedure attempted or performed on patient Provider of First CPR Person who performed first CPR on patient Provider Impression Provider's clinical impression which led to the treatment given to the patient Pulse Rate Patient's palpated or auscultated pulse rate expressed in beats per minute Race/Ethnicity Patient's racial and ethnic origin

- 3 -

NAME DEFINITION Respiratory Effort Patient's respiratory effort expressed in phases 0 - 3 Respiratory Rate Unassisted patient respiratory rate expressed in breaths per minute Response Number Unique number for each individual response by a response unit to an incident Return of Spontaneous Circulation Whether a palpable pulse of blood pressure was restored following cardiac arrest and resuscitation in the field Revised Trauma Score Patient's revised trauma score Rhythm at Destination Monitored cardiac rhythm upon arrival at destination Safety Equipment Safety equipment in use by patient at time of injury Service Type Type of service requested by initial caller Signs and Symptoms Present Signs and symptoms reported to or observed by provider Skin Perfusion Patient's skin perfusion expressed as normal or decreased Social Security Number Patient's Social Security number State of Residence State, territory, province, or District of Columbia, where patient resides Suspected Alcohol/Drug Use Suspected alcohol or drug use by patient Systolic Blood Pressure Patient's systolic blood pressure Telephone Number Patient's primary telephone number Time Back in Service Time that response unit was back in service, available for response Time CPR Discontinued Time at which medical control or responding unit terminated resuscitation efforts in the field Time Dispatch Notified Time of first connection with EMS dispatch Time Incident Reported Time call was first received by dispatch or other designated entity Time of Arrival at Destination Time when patient arrived at destination or transfer point Time of Arrival at Patient Time response personnel established first direct contact with patient Time of Arrival at Scene Time EMS response unit stopped physical motion at scene (last place unit or vehicle stops prior to assessing patient)

- 4 -

NAME DEFINITION Time of First CPR Best estimate of time of first CPR Time of First Defibrillatory Shock Time of first defibrillatory shock Time of Cardiac Arrest Time of cardiac arrest (witnessed) Time Transport Unit Left Scene Time transport unit physically left the scene in transport Time Unit Notified Time response unit was notified by EMS dispatch Time Unit Responding Time response unit began physical motion Treatment Authorization Source of authorization for treatment Vehicle Type Type of vehicle that responded to incident Witness of Cardiac Arrest Person who witnessed cardiac arrest Zip Code of Residence Zip code of patient's residence